Care Coordination

• Collaborative care solutions that reflect the continuum of information on a patient and support team based care, management of patients by risk category, secure messaging, and transitions of care.

Analytics

• Retrospective and predictive analyses related to care coordination, quality management, and decision support.
• Tools capable of identifying high risk patients and notifying patients of follow-up care appointments, based on standard criteria for risk.
• Analytic capabilities that take into account both quality and financial measures to adequately identify risk.
• Statistical tools related to quality improvement and public health reporting.

Message Alerts

• Alert tools that provide a secure and standardized messaging environment for accurate communication and information exchange between transferring and receiving provider.
• Clinical decision support including point-of-care alerts indicating transitions in care settings, hospitalizations, medication changes, discharges, non-medical referrals, and other medical changes to care plan.

Patient Engagement

• Personal health management solutions that facilitate better healthcare decisions and help improve communication on care management between the provider and the patient and/or family members. Patient engagement tools need to span the possibilities of innovation and present a wide range of options that allow for easy access by patients.
• Examples of innovations in this focus area include but are not limited to telehealth, consent management, patient portals, personal health records, medication adherence, caregiver tools, appointment scheduling, tools that facilitate self-management and capture health risk behaviors, preventive care elements, community resources, health and wellness tools, patient understandable lab results, etc.